ENCINADA, REGINE MAE M.

BSN 4
Fundamentals of Nursing NCLEX Practice Questions Quiz #4

1. All of the following can cause tachycardia except:

A. Fever
B. Exercise
C. Sympathetic nervous system stimulation
D. Parasympathetic nervous system stimulation

2. Palpating the midclavicular line is the correct technique for assessing:

A. Baseline vital signs

B. Systolic blood pressure
C. Respiratory rate
D. Apical pulse

3. The absence of which pulse may not be a significant finding when a patient is admitted to
the hospital?

A. Apical
B. Radial
C. Pedal
D. Femoral

4. Which of the following patients is at greatest risk for developing pressure ulcers?

A. An alert, chronic arthritic patient treated with steroids and aspirin.

B. An 88-year old incontinent patient with gastric cancer who is confined to his bed at
home.
C. An apathetic 63-year old COPD patient receiving nasal oxygen via cannula.
D. A confused 78-year old patient with congestive heart failure (CHF) who requires
assistance to get out of bed.

5. The physician orders the administration of high-humidity oxygen by face mask and
placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse
writes the following nursing diagnosis: Impaired gas exchange related to increased secretions.
Which of the following nursing interventions has the greatest potential for improving this
situation?

A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours.
B. Place a humidifier in the patient’s room.
C. Continue administering oxygen by a high humidity face mask.
D. Perform chest physiotherapy on a regular schedule.

6. The most common deficiency seen in alcoholics is:

A. Thiamine
B. Riboflavin
C. Pyridoxine
D. Pantothenic acid

7. Which of the following statements is incorrect about a patient with dysphagia?

A. The patient will find pureed or soft foods, such as custards, easier to swallow than water.
B. Fowler’s or semi Fowler’s position reduces the risk of aspiration during swallowing.
C. The patient should always feed himself.
D. The nurse should perform oral hygiene before assisting with feeding.

8. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the
nurse measures his hourly urine output. She should notify the physician if the urine output is:

A. Less than 30 ml/hour

B. 64 ml in 2 hours
C. 90 ml in 3 hours
D. 125 ml in 4 hours

9. Certain substances increase the amount of urine produced. These include:

A. Caffeine-containing drinks, such as coffee and cola

B. Beets
C. Urinary analgesics
D. Kaolin with pectin (Kaopectate)

10. A male patient who had surgery 2 days ago for head and neck cancer is about to make his
first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and
that his vision was unaffected by the surgery. Which of the following nursing interventions
would be appropriate?

A. Encourage the patient to walk in the hall alone.

B. Discourage the patient from walking in the hall for a few more days.
C. Accompany the patient for his walk.
D. Consult a physical therapist before allowing the patient to ambulate.

11. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested
by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An
appropriate nursing diagnosis would be:

A. Ineffective airway clearance related to thick, tenacious secretions

B. Ineffective airway clearance related to dry, hacking cough
C. Ineffective individual coping to COPD
D. Pain related to immobilization of affected leg

12. Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be:

A. “Don’t worry. It’s only temporary”

B. “Why are you crying? I didn’t get to the bad news yet”
C. “Your hair is really pretty”
 D. “I know this will be difficult for you, but your hair will grow back after the
completion of chemotherapy”

13. An additional Vitamin C is required during all of the following periods except:

A. Infancy
B. Young adulthood
C. Childhood
D. Pregnancy

14. A prescribed amount of oxygen is needed for a patient with COPD to prevent:

A. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood
(PaCO2).
B. Circulatory overload due to hypervolemia.
C. Respiratory excitement.
D. Inhibition of the respiratory hypoxic stimulus.

15. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following
is the most significant symptom of his disorder?

A. Lethargy
B. Increased pulse rate and blood pressure
C. Muscle weakness
D. Muscle irritability

16. Which of the following nursing interventions promotes patient safety?

A. Assess the patient’s ability to ambulate and transfer from a bed to a chair.
B. Demonstrate the signal system to the patient.
C. Check to see that the patient is wearing his identification band.
D. All of the above.

17. Studies have shown that about 40% of patients fall out of bed despite the use of side rails;
this has led to which of the following conclusions?

A. Side rails are ineffective.

B. Side rails should not be used.
C. Side rails are a deterrent that prevent a patient from falling out of bed.
D. Side rails are a reminder to a patient not to get out of bed.

18. Examples of patients suffering from impaired awareness include all of the following
except:

A. A semiconscious or over fatigued patient.

B. A disoriented or confused patient.
C. A patient who cannot care for himself at home.
D. A patient demonstrating symptoms of drugs or alcohol withdrawal.
19. The most common injury among elderly persons is:

A. Atherosclerotic changes in the blood vessels

B. Increased incidence of gallbladder disease
C. Urinary Tract Infection
D. Hip fracture

20. The most common psychogenic disorder among elderly person is:

A. Depression
B. Sleep disturbances (such as bizarre dreams)
C. Inability to concentrate
D. Decreased appetite

21. Which of the following vascular system changes results from aging?

A. Increased peripheral resistance of the blood vessels

B. Decreased blood flow
C. Increased workload of the left ventricle
D. All of the above

22. Which of the following is the most common cause of dementia among elderly persons?

A. Parkinson’s disease
B. Multiple sclerosis
C. Amyotrophic lateral sclerosis (Lou Gehrig’s disease)
D. Alzheimer’s disease

23. The nurse’s most important legal responsibility after a patient’s death in a hospital is:

A. Obtaining a consent of an autopsy.

B. Notifying the coroner or medical examiner.
C. Labeling the corpse appropriately.
D. Ensuring that the attending physician issues the death certification.

24. Before rigor mortis occurs, the nurse is responsible for:

A. Providing a complete bath and dressing change.

B. Placing one pillow under the body’s head and shoulders.
C. Removing the body’s clothing and wrapping the body in a shroud.
D. Allowing the body to relax normally.

25. When a patient in the terminal stages of lung cancer begins to exhibit loss of
consciousness, a major nursing priority is to:

A. Protect the patient from injury.

B. Insert an airway.
C. Elevate the head of the bed.
D. Withdraw all pain medications.
26. Which element in the circular chain of infection can be eliminated by preserving skin
integrity?

A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry

27. Which of the following will probably result in a break in sterile technique for respiratory
isolation?

A. Opening the patient’s window to the outside environment.

B. Turning on the patient’s room ventilator.
C. Opening the door of the patient’s room leading into the hospital corridor.
D. Failing to wear gloves when administering a bed bath.

28. Which of the following patients is at greater risk for contracting an infection?

A. A postoperative patient who has undergone orthopedic surgery.

B. A patient receiving broad-spectrum antibiotics.
C. A patient with leukopenia.
D. A newly diagnosed diabetic patient.

29. Effective handwashing requires the use of:

A. Soap or detergent to promote emulsification.

B. Hot water to destroy bacteria.
C. A disinfectant to increase surface tension.
D. All of the above.

30. After routine patient contact, handwashing should last at least:

A. 30 seconds
B. 1 minute
C. 2 minutes
D. 3 minutes

31. Which of the following procedures always requires surgical asepsis?

A. Vaginal instillation of conjugated estrogen

B. Urinary catheterization
C. Nasogastric tube insertion
D. Colostomy irrigation

32. Sterile technique is used whenever:

A. Strict isolation is required

B. Terminal disinfection is performed
C. Invasive procedures are performed
D. Protective isolation is necessary

33. Which of the following constitutes a break in sterile technique while preparing a sterile
field for a dressing change?

A. Using sterile forceps, rather than sterile gloves, to handle a sterile item.
B. Touching the outside wrapper of sterilized material without sterile gloves.
C. Placing a sterile object on the edge of the sterile field.
D. Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a
sterile container.

34. A natural body defense that plays an active role in preventing infection is:

A. Yawning
B. Body hair
C. Hiccupping
D. Rapid eye movements

35. All of the following statement are true about donning sterile gloves except:

A. The first glove should be picked up by grasping the inside of the cuff.
B. The second glove should be picked up by inserting the gloved fingers under the cuff
outside the glove.
C. The gloves should be adjusted by sliding the gloved fingers under the sterile cuff and
pulling the glove over the wrist.
D. The inside of the glove is considered sterile.

36. When removing a contaminated gown, the nurse should be careful that the first thing she
touches is the:

A. Waist tie and necktie at the back of the gown

B. Waist tie in front of the gown
C. Cuffs of the gown
D. Inside of the gown

37. nursing interventions is considered the most effective form for universal precautions?

A. Cap all used needles before removing them from their syringes.
B. Discard all used uncapped needles and syringes in an impenetrable protective
container.
C. Wear gloves when administering IM injections.
D. Follow enteric precautions.

38. All of the following measures are recommended to prevent pressure ulcers except:

A. Massaging the reddened area with lotion.

B. Using a water or air mattress.
C. Adhering to a schedule for positioning and turning.
D. Providing meticulous skin care.

39. Which of the following blood tests should be performed before a blood transfusion?

A. Prothrombin and coagulation time

B. Blood typing and cross-matching
C. Bleeding and clotting time
D. Complete blood count (CBC) and electrolyte levels

40. The primary purpose of a platelet count is to evaluate the:

A. Potential for clot formation

B. Potential for bleeding
C. Presence of an antigen-antibody response
D. Presence of cardiac enzymes

41. Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?

A. 4,500/mm³
B. 7,000/mm³
C. 10,000/mm³
D. 25,000/mm³

42. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins
to exhibit fatigue, muscle cramping, and muscle weakness. These symptoms probably
indicate that the patient is experiencing:

A. Hypokalemia
B. Hyperkalemia
C. Anorexia
D. Dysphagia

43. Which of the following statements about chest X-rays is not true?

A. No contradictions exist for this test.

B. Before the procedure, the patient should remove all jewelry, metallic objects, and buttons
above the waist.
C. A signed consent is not required.
D. Eating, drinking, and medications are allowed before this test.

44. The most appropriate time for the nurse to obtain a sputum specimen for culture is:

A. Early in the morning

B. After the patient eats a light breakfast
C. After aerosol therapy
D. After chest physiotherapy
45. A patient with no known allergies is to receive penicillin every 6 hours. When
administering the medication, the nurse observes a fine rash on the patient’s skin. The most
appropriate nursing action would be to:

A. Withhold the moderation and notify the physician.

B. Administer the medication and notify the physician.
C. Administer the medication with an antihistamine.
D. Apply cornstarch soaks to the rash.

46. All of the following nursing interventions are correct when using the Z-track method of
drug injection except:

A. Prepare the injection site with alcohol.

B. Use a needle that’s at least 1” long.
C. Aspirate for blood before injection.
D. Rub the site vigorously after the injection to promote absorption.

47. The correct method for determining the vastus lateralis site for I.M. injection is to:

A. Locate the upper aspect of the upper outer quadrant of the buttock about 5 to 8 cm below
the iliac crest.
B. Palpate the lower edge of the acromion process and the midpoint lateral aspect of the arm.
C. Palpate a 1” circular area anterior to the umbilicus.
D. Divide the area between the greater femoral trochanter and the lateral femoral
condyle into thirds, and select the middle third on the anterior of the thigh.

48. The mid-deltoid injection site is seldom used for I.M. injections because it:

A. Can accommodate only 1 ml or less of medication.

B. Bruises too easily.
C. Can be used only when the patient is lying down.
D. Does not readily absorb parenteral medication.

49. The appropriate needle size for insulin injection is:

A. 18G, 1 ½” long
B. 22G, 1” long
C. 22G, 1 ½” long
D. 25G, 5/8” long

50. The appropriate needle gauge for intradermal injection is:

A. 20G
B. 22G
C. 25G
D. 26G
51. Parenteral penicillin can be administered as an:

A. IM injection or an IV solution
B. IV or an intradermal injection
C. Intradermal or subcutaneous injection
D. IM or a subcutaneous injection

52. The physician orders gr 10 of aspirin for a patient. The equivalent dose in milligrams is:

A. 0.6 mg
B. 10 mg
C. 60 mg
D. 600 mg

53. The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would
the flow rate be if the drop factor is 15 gtt = 1 ml?

A. 5 gtt/minute
B. 13 gtt/minute
C. 25 gtt/minute
D. 50 gtt/minute

54. Which of the following is a sign or symptom of a hemolytic reaction to blood

transfusion?

A. Hemoglobinuria
B. Chest pain
C. Urticaria
D. Distended neck veins

55. Which of the following conditions may require fluid restriction?

A. Fever
B. Chronic Obstructive Pulmonary Disease
C. Renal Failure
D. Dehydration

56. All of the following are common signs and symptoms of phlebitis except:

A. Pain or discomfort at the IV insertion site

B. Edema and warmth at the IV insertion site
C. A red streak exiting the IV insertion site
D. Frank bleeding at the insertion site

57. The best way of determining whether a patient has learned to instill ear medication
properly is for the nurse to:
A. Ask the patient if he/she has used ear drops before.
B. Have the patient repeat the nurse’s instructions using her own words.
C. Demonstrate the procedure to the patient and encourage to ask questions.
D. Ask the patient to demonstrate the procedure.

58. Which of the following types of medications can be administered via gastrostomy tube?

A. Any oral medications.

B. Capsules' whole contents are dissolved in water.
C. Enteric-coated tablets that are thoroughly dissolved in water.
D. Most tablets designed for oral use, except for extended-duration compounds.

59. A patient who develops hives after receiving an antibiotic is exhibiting drug:

A. Tolerance
B. Idiosyncrasy
C. Synergism
D. Allergy

60. A patient has returned to his room after femoral arteriography. All of the following are
appropriate nursing interventions except:

A. Assess femoral, popliteal, and pedal pulses every 15 minutes for 2 hours.
B. Check the pressure dressing for sanguineous drainage.
C. Assess vital signs every 15 minutes for 2 hours.
D. Order a hemoglobin and hematocrit count 1 hour after the arteriography.

61. The nurse explains to a patient that a cough:

A. Is a protective response to clear the respiratory tract of irritants.

B. Is primarily a voluntary action.
C. Is induced by the administration of an antitussive drug.
D. Can be inhibited by “splinting” the abdomen.

62. An infected patient has chills and begins shivering. The best nursing intervention is to:

A. Apply iced alcohol sponges

B. Provide increased cool liquids
C. Provide additional bedclothes
D. Provide increased ventilation

63. A clinical nurse specialist is a nurse who has:

A. Been certified by the National League for Nursing.

B. Received credentials from the American Nurses’ Association.
C. Graduated from an associate degree program and is a registered professional nurse.
D. Completed a master’s degree in the prescribed clinical area and is a registered
professional nurse.

64. The purpose of increasing urine acidity through dietary means is to:
A. Decrease burning sensations
B. Change the urine’s color
C. Change the urine’s concentration
D. Inhibit the growth of microorganisms

65. Clay-colored stools indicate:

A. Upper GI bleeding
B. Impending constipation
C. An effect of medication
D. Bile obstruction

66. In which step of the nursing process would the nurse ask a patient if the medication she
administered relieved his pain?

A. Assessment
B. Analysis
C. Planning
D. Evaluation

67. All of the following are good sources of vitamin A except:

A. White potatoes
B. Carrots
C. Apricots
D. Egg yolks
.
68. Which of the following is a primary nursing intervention necessary for all patients with a
Foley Catheter in place?

A. Maintain the drainage tubing and collection bag level with the patient’s bladder.
B. Irrigate the patient with 1% Neosporin solution three times a day.
C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity.
D. Maintain the drainage tubing and collection bag below bladder level to facilitate
drainage by gravity.

69. The ELISA test is used to:

A. Screen blood donors for antibodies to human immunodeficiency virus (HIV).

B. Test blood to be used for transfusion for HIV antibodies.
C. Aid in diagnosing a patient with AIDS.
D. All of the above.

70. The two blood vessels most commonly used for TPN infusion are the:

A. Subclavian and jugular veins

B. Brachial and subclavian veins
C. Femoral and subclavian veins
D. Brachial and femoral veins
71. Effective skin disinfection before a surgical procedure includes which of the following
methods?

A. Shaving the site on the day before surgery.

B. Applying a topical antiseptic to the skin in the evening before surgery.
C. Having the patient take a tub bath on the morning of surgery.
D. Having the patient shower with an antiseptic soap on the evening before and the
morning of surgery.

72. When transferring a patient from a bed to a chair, the nurse should use which muscles to
avoid back injury?

A. Abdominal muscles
B. Back muscles
C. Leg muscles
D. Upper arm muscles

73. Thrombophlebitis typically develops in patients with which of the following conditions?

A. Increases partial thromboplastin time

B. Acute pulsus paradoxus
C. An impaired or traumatized blood vessel wall
D. Chronic Obstructive Pulmonary Disease (COPD)

74. In a recumbent, immobilized patient, lung ventilation can become altered, leading to such
respiratory complications as:

A. Respiratory acidosis, atelectasis, and hypostatic pneumonia

B. Apneustic breathing, atypical pneumonia and respiratory alkalosis
C. Cheyne-Stokes respirations and spontaneous pneumothorax
D. Kussmaul’s respirations and hypoventilation

75. Immobility impairs bladder elimination, resulting in such disorders as:

A. Increased urine acidity and relaxation of the perineal muscles, causing incontinence
B. Urine retention, bladder distention, and infection
C. Diuresis, natriuresis, and decreased urine specific gravity
D. Decreased calcium and phosphate levels in the urine